CurrentEmblemHealthPolicy RPC20230038

Facility Fees for E&M Services on Outpatient Facility Claims (Commercial & Medicare)

This reimbursement policy governs when EmblemHealth will deny evaluation and management (E&M) codes billed on outpatient facility (UB-04) claims for Commercial and Medicare products, and instructs appropriate billing on professional (CMS-1500) claims for clinic/office services. It affects facility providers, professional providers, and billing staff submitting outpatient facility claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyFacility Fees for E&M Services on Outpatient Facility Claims (Commercial & Medicare)

Policy CodePolicy RPC20230038

Change TypeRemoved Medicaidclarified G0463 off-campus reportingtemplate formatting

Effective DateMar 1, 2024

Next Review Date

Key ActionDo not bill E&M codes on UB-04 outpatient facility claims; bill clinic/office services on CMS-1500 with place of service 'office'.

SourceLink

POLICY UPDATE CHANGES

Transferred policy content to individual company-branded template.

Medicaid as an applicable line of business was removed.

Clarified that EmblemHealth follows CMS guidelines regarding off-campus provider-based department/clinic reporting requirements for G0463.

3/1/2024policy effective date

Commercial & Medicareapplicable product lines

Denies E&M on UB-04payment stance

Extensive listcodes referenced

Denial and Billing Rules for Outpatient E&M Services

Denial and billing rules for outpatient E&M services

Covered when ALL of the following conditions apply:

EmblemHealth will deny services on outpatient facility (UB-04) claims when evaluation and management (E&M) codes are billed.

Clinic services rendered in an office, professional building, medical office building, free-standing clinic, or any space on a facility campus that is owned by or rented from the facility must be billed on a CMS-1500 (professional) claim form with place of service 'office'.

Facility providers must not bill the Health Plan for off-campus clinic charges for technical components or overhead expenses (including use of the space where professional services are provided).

The covered individual will not be responsible for clinic charges billed by the facility for these services.

Exceptions

Policy Summary

PayerEmblemHealth

PolicyFacility Fees for E&M Services on Outpatient Facility Claims (Commercial & Medicare)

Policy CodePolicy RPC20230038

Change TypeRemoved Medicaidclarified G0463 off-campus reportingtemplate formatting

Effective DateMar 1, 2024

Next Review Date

Key ActionDo not bill E&M codes on UB-04 outpatient facility claims; bill clinic/office services on CMS-1500 with place of service 'office'.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Enumerated E&M and Related Codes

Covered CPT/HCPCS Codes - E&M and RelatedmixedCovered

99202	Office/outpatient visit, new patient
99203	Office/outpatient visit, new patient
99204	Office/outpatient visit, new patient
99205	Office/outpatient visit, new patient
99211	Office/outpatient visit, established patient
99212	Office/outpatient visit, established patient
99213	Office/outpatient visit, established patient
99214	Office/outpatient visit, established patient
99215	Office/outpatient visit, established patient
99221	Initial hospital inpatient care

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G0463 handling — follow EmblemHealth Modifiers PN & PO guidance and CMS off-campus provider-based department rules

G0463 handlingFollow EmblemHealth Modifiers PN & PO guidance and CMS off-campus provider-based department rules when billing G0463; ensure correct modifier usage to avoid claim denials.

Billing Requirements and Denial Risk

Denial Risk

Do not bill E&M on UB‑04 — bill on CMS‑1500 (POS 'office')

Do not submit evaluation and management (E&M) codes on UB-04 outpatient facility claims. EmblemHealth will deny services on outpatient facility (UB-04) claims when E&M codes are billed; clinic services rendered in office, professional building, medical office building, free‑standing clinic, or any space on a facility campus owned or rented by the facility must be billed on a CMS‑1500 (professional) claim form with place of service 'office'.

EmblemHealth will deny services on outpatient facility claims with E&M codes billed on a UB‑04 (Effective 3/1/2024).
Clinic services provided in offices, professional buildings, medical office buildings, free‑standing clinics, or any space owned or rented by a hospital/health system must be billed on CMS‑1500 with place of service 'office'.
Facility providers must not bill the Health Plan for off‑campus clinic charges for technical component or overhead; the professional provider should bill the professional claim.

Definitions Related to Clinic/Office Services Billing

Outpatient facility (UB-04) with E&M codes — billing and denial

Billing ruleE&M codes billed on outpatient facility (UB‑04) claims are considered facility billing of clinic/office visits and will be denied.

Required formClinic/office services rendered in office, professional building, medical office building, free‑standing clinic, or any space on a facility campus owned or rented by the facility must be billed on a CMS‑1500 (professional) claim form with place of service 'office'.

Off‑campus clinicsFacility providers should not bill the Health Plan for off‑campus clinic charges for technical components or overhead; professional provider should bill the service.

Member liabilityThe covered individual will not be responsible for clinic charges billed by the facility for these services.